Question

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Answer 1

Correct Answers:

Profuse diaphoresis and severe, pounding headache.

Rationale :

💢Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia, a life-threatening complication of spinal cord injury at or above the T6 level.

🚽A full bladder is a common trigger, leading to sympathetic nervous system overactivation, causing sudden hypertension and excessive sweating.

🧠The brain responds by attempting to lower blood pressure, but the signal cannot pass below the injury site, resulting in uncontrolled autonomic output.

⚠️The other options, such as hypotension or urinary symptoms, may reflect other conditions but do not point specifically to autonomic dysreflexia.

📌Core Message

Autonomic dysreflexia presents with hypertension, diaphoresis, and headache due to stimuli like a full bladder in clients with spinal injuries at or above T6.

Answer 2

Correct Answers:

Washes the radiation site with antibacterial soap and water.

Rationale :

🧼Using antibacterial soap on irradiated skin can cause irritation and dryness, worsening the tissue damage from radiation therapy.

🩹Radiation sites should be cleaned with mild, fragrance-free soaps to preserve skin integrity and promote healing.

🧴Prescribed lotions are often included to maintain hydration and soothe the area, making their use appropriate.

👕Wearing protective clothing shields the area from sun exposure and further irritation, supporting skin healing.

📌Core Message

Antibacterial soaps are too harsh for radiated skin, which requires gentle cleansing and moisturization to avoid complications.

Answer 3

Correct Answers:

Lumbar puncture.

Rationale :

💉A lumbar puncture is the most definitive test for bacterial meningitis, allowing analysis of cerebrospinal fluid (CSF) for infection markers.

🧪Findings such as elevated white cells, protein, and low glucose help confirm diagnosis and guide treatment.

🧲MRI or CT scans may be done before the LP if increased intracranial pressure is suspected, but they do not confirm meningitis.

📸Skull radiographs are outdated and not useful in evaluating central nervous system infections.

📌Core Message

A lumbar puncture provides critical information to confirm bacterial meningitis by analyzing cerebrospinal fluid.

Answer 4

Correct Answers:

Auscultate bowel sounds.

Rationale :

👂Auscultating bowel sounds is the best way to assess for postoperative ileus, a common complication after abdominal surgery.

🌀Symptoms like nausea and abdominal pressure may signal impaired gastrointestinal motility, which requires early detection.

🚶‍♂️While ambulation encourages bowel activity, it should not precede proper assessment of bowel sounds.

✋Palpation comes after auscultation to prevent altering the natural peristaltic sounds heard during assessment.

📌Core Message

Postoperative nausea and abdominal pressure require bowel sound assessment to detect ileus or delayed GI recovery.

Answer 5

Correct Answers:

The client's hemoglobin A1C will be less than 7% in 3 months.

Rationale :

🧪A hemoglobin A1C target of <7% indicates good glycemic control, which is a standard outcome for type 2 diabetes management.

👁️Blurred vision may be linked to hyperglycemia, which affects ocular perfusion and lens shape, making A1C control crucial.

🧍While exercise and BP control are important, they are not as specific or measurable in addressing the acute diabetic goal.

📘Nursing demonstration is an intervention, not a client-centered outcome.

📌Core Message

Managing type 2 diabetes includes targeting A1C <7% to reduce complications like blurred vision and optimize control.

Answer 6

Correct Answers:

Full-thickness.

Rationale :

🔥Full-thickness burns appear brown or yellow, are painless due to nerve destruction, and exhibit thick eschar with possible edema.

🧊This classification involves all skin layers, sometimes extending to fat, muscle, or bone, and typically requires surgical intervention.

🩹Partial-thickness burns are painful, often with blisters and intact nerve endings, which is inconsistent with the scenario.

📛Deep full-thickness is a more extensive version but typically described with charred or leathery appearance, not just brown/yellow.

📌Core Message

Full-thickness burns present with painless, discolored wounds due to nerve damage and deep tissue involvement.

Answer 7

Correct Answers:

Demonstrate the use of visual scanning during meals to the client and family.

Rationale :

👁️Visual scanning compensates for unilateral neglect or visual field deficits, common after stroke, especially with right hemisphere involvement.

🍽️Demonstrating this strategy improves nutritional intake by helping clients recognize food on the entire plate.

🏠Home food may provide comfort but doesn’t address the underlying deficit.

👨‍👩‍👧Family assistance in feeding can reduce independence if used prematurely without rehabilitation strategies.

📌Core Message

Teaching visual scanning improves meal intake and compensates for visual deficits after a stroke.

Answer 8

Correct Answers:

Bounding pulse, hypertension, and distended neck veins.

Rationale :

💓A bounding pulse, hypertension, and jugular vein distention are hallmark signs of fluid overload, especially concerning in older adults.

🩸Whole blood transfusions pose volume risks, and older adults have reduced cardiac reserve, increasing the overload risk.

❄️Fever and chills reflect febrile transfusion reactions, not overload.

😖Thready pulses and hypotension are signs of hypovolemia or shock, not volume excess.

📌Core Message

Monitor for bounding pulse, HTN, and distended neck veins to detect fluid overload during transfusion in older adults.

Answer 9

Correct Answers:

Immobilize the head in anatomical alignment.

Rationale :

🧠Immobilizing the head and cervical spine is the top priority to prevent further spinal cord damage after cervical injury.

🛏️Any movement can worsen neurologic outcomes, so stabilization must occur immediately upon suspicion of injury.

📊Hourly neuro checks and reflex assessments are important but must follow initial stabilization.

🔄Logrolling helps prevent movement but must occur only after immobilization is secured.

📌Core Message

Immediately immobilize the head and cervical spine to prevent worsening spinal cord injury after cervical trauma.

Answer 10

Correct Answers:

Check the abdominal surgical dressing.

Rationale :

🩸A sudden drop in blood pressure after abdominal surgery could indicate internal bleeding, requiring prompt wound assessment.

🧻Inspecting the dressing helps identify excess drainage, saturation, or hematoma, which may be the source of volume loss.

📉Monitoring vitals is important but secondary to identifying the bleeding source.

📚Reviewing BP trends helps with pattern recognition but does not address active issues.

💨Encouraging deep breathing supports recovery but doesn’t address potential hypovolemia.

📌Core Message

First step for a post-op BP drop is to assess for bleeding at the surgical site, starting with the dressing inspection.

1 :
A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

2 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

3 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

4 :
Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

5 :
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

6 :
The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

7 :
An older adult client who experienced a cerebrovascular accident (CV).

8 :
The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

9 :
When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

10 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

1 : A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

2 : The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

3 : The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

4 : Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

5 : The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

6 : The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

7 : An older adult client who experienced a cerebrovascular accident (CV).

8 : The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

9 : When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

10 : One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?

1 :
A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

2 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

3 :
The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

4 :
Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

5 :
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

6 :
The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

7 :
An older adult client who experienced a cerebrovascular accident (CV).

8 :
The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

9 :
When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

10 :
One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later, it is 114/72 mm Hg. Which action should the nurse take first?